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General NPI Number Information
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NPI Number | 1649497587
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Entity Type | Individual
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Provider Name | NICHOLAS JAMES MARTIN PHARM. D.
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Gender | Male
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3865 GRAVOIS AVE PHARMACY
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City | SAINT LOUIS
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State | MO
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Zip | 63116-4657
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Country | US
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Telephone | 314-771-0218
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Fax |
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Provider Business Mailing Address
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Address Line | 2501 CONIFEROUS DR
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City | BELLEVILLE
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State | IL
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Zip | 62221-7960
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Country | US
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Telephone | 314-435-7344
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 2006024033
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License Number State | MO
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